60, is it the magic number when caring for infants?
Yes!!
Why is 60 the magic number?
When assessing an infant’s vital signs my preceptors taught me to count the heart rate and respiratory rate for
60 seconds to make sure I was getting the whole picture.
We often hold feedings if the infant’s respiratory rate is 60 or above.
In BLS (basic life support) & PALS (pediatric advanced life support) we learn to start compressions on a small child
if the heart rate is 60 or below.
Why do we count the Heart Rate for 60 seconds?
Some normal variation in heart rhythm can occur along with breathing in infants. This slight change in their heart rate makes it important to listen to an infant’s heart for a full minute in order to get an accurate reading.
If you only listen for 10-15 seconds, you may not get the whole picture because it could be a timespan that was during a pause or acceleration.
Example:
If I listen to a baby’s heart for 15 seconds during a time of acceleration, I may hear 30 beats and multiply that by 4 to get their rate/minute.
That would give me a heart rate of 120.
If I listen during a slower period I may hear 20 beats per 15 seconds and calculate a rate of 80.
However, if I listen the whole minute, their heart rate may actually be around 100.
Why do infants have some normal variation in their heart rhythm and rate?
When an infant takes a breath in, the chest cavity expands and negative pressure is created in the chest. During inspiration, a little extra blood returns to the heart and the volume increases slightly.
When a child is relatively healthy, this causes a slight “stretch” and the heart can temporarily speed up. The opposite happens with exhalation and can temporarily slow the heart rate.
Note about an infant’s heart rate & cardiac output:
If your assessment reveals that an infant’s work of breathing is increasing (retractions, nasal flaring, mouth breathing, wheezing etc), they are most likely “compensating” for decreased perfusion and lack of oxygen.
If they need extra perfusion/oxygen, their compensation mechanism will be through increased heart rate and respiratory rate.
Increasing their heart rate is the only way that infants can increase their cardiac output.
Their bodies are not able to change their stroke volume until they are closer to school age.
If the infant is a newborn or NICU baby, we would follow Neonatal Resuscitation parameters (NRP) (which are slightly different than PALS).
What happens when a small child has a heart rate of 60 or below?
We start compressions.
Generally, a heart rate of 60 or below is not sufficient for an infant to perfuse enough oxygen throughout their body.
There are exceptions to this rule.
For example, if a child is bradycardic but alert, talking and pink, we would not start compressions.
Or if we feel that giving oxygen would help increase the heart rate quickly and reverse the bradycardia, we may hold off for 30 seconds or so while administering high flow oxygen.
When assessing an infant’s respiratory rate, we listen for 60 seconds
The most reliable method for measuring an infant’s breathing is to listen and watch for 60 seconds.
Infants may breathe fast a few times, then have brief periods of apnea (10 seconds), then breath again.
This is normal and called periodic breathing.
I you listen and watch for 15 seconds and multiply that times 4, like we do for most adults, you could be measuring during a faster or slower period giving you false results.
Refresher: Infants in respiratory distress may also breathe in uneven patterns.
At what respiratory rate do we hold feedings until it drops? …you guessed it….60
Infants in respiratory distress who are breathing too rapidly (greater than 60) may aspirate when they are feeding.
Infants are obligate nose breathers which means that they breathe through their nose. The exception to this is when they are crying and they do breath through their mouth during that time.
When they are in respiratory distress, they may breathe rapidly (usually with a stuffy nose) and try to swallow at the same time. If they are breathing too rapidly, this causes the risk for aspiration.
The respiratory rate we usually start holding feedings to decrease this risk is 60.
If we can get the respiratory rate to go down through medical or nursing interventions such as CPT (chest physiotherapy), breathing treatments, suctioning, oxygen etc., the baby can usually resume normal eating.
If we are not able to decrease the rate in a reasonable timeframe, the provider may seek a longer-term feeding solution.
NOTE:
Keep in mind, these are generalizations and a good way to remember these parameters.
There are always exceptions based on a child’s condition and their baseline.
Newborns and NICU babies may have different guidelines than slightly older infants.
This article is based on the references below and my training as a pediatric nurse in an acute care pediatric inpatient setting.
Your protocols and orders may be slightly different in your setting. Please check your policies and procedures to make sure you know the standards of care for your work setting.
Need a quick overview?
60 is the magic number because:
We count an infant’s respiratory rate by auscultating (listening) and watching for a full 60 seconds
We count an infant’s heart rate by auscultating (listening) for a full 60 seconds
If an infant is breathing > 60 times per minute, notify the provider, they will most likely want to hold feedings and change or include more interventions.
If an infant’s heart rate is less than 60 start compressions (see above for more details)
Do you have any memory tools or a pneumonic you’d like to share from your nursing experience?
Are there any topics you’d like for me to cover in another blog post?
I’d love to hear about them, leave a comment below or email me at brandijonesLLC@gmail.com.
References:
Choanal Atresia. (2019). Minnesota Department of Health. 2019. Retrieved December, 2020 from:
Pediatric Basic and Advanced Life Support. (2020). US Department of Health & Human Services. Retrieved December, 2020 from:
https://chemm.nlm.nih.gov/pals.htm#sec2
Villines, Z. (2019). What to know about newborn respiratory rates. Medical News Today. Retrieved December, 2020 from:
https://www.medicalnewstoday.com/articles/327164#measurement
